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7. <br />8. <br />9. <br />10. <br />List Dock location and ownership information; <br />Street address Lq45 IX *l/' I ^ <br />Legal property description Si,I AILAm.JI A_____________ <br />PID# <br />Listed property owner(s) Xhc . <br />fo m /ov s03i <br />Names/addresses of abutting lakeshore property owners; <br />fNoith/Westl __________________ <br />fSouth/Eastl a/a <br />Names/addresses of other affected property owners (attach sheet if necessary); <br />______________ A/A- <br />Insurance Coverage - The jointly used dock is insured by one of the following; <br />__property owner's homeowner’s policy. separate group/association owned policy. <br />Name of insured_ <br />Name of insurance carrier .1 jge <br />»» *- /.AlName of insurance agency ^ L^rg6t^ TTnd , _______ <br />Policy No. Effective date of coverage (#/ja/o< (//jk^/qi/ <br />Amount of coverage; Public liability, per person, per occurrence $ /, ’ <br />Public liability, per occurrence $ I CJITD COn>______ <br />Security and policing of the jointly used dock and property is provided by (check applicable <br />items): <br />fencing ____ security lighting ____property owner's presence <br />contract security service .X other (specify) < <br />ILJ3 <br />11. <br />>CK INFORMATION <br />List Dock Use Area Specifications: < !' <br />Width of shoreline; ft. Length of main dock firom shore; <br />Dock setbacks fiom side property lines at shore;_________ft. and <br />ft. <br />ft. <br />12. Do^ Construction (check applicable items): <br />^ seasonal dock ^relocated or reolaced iseasonal dock (relocated or replaced each year) <br />permanent piling with seasonal deck ____ permanent piling and decking <br />X wooden decking metal decking <br />Page 2 of 4 <br />. I »i